The extent of albuminuria in individuals with diabetes within Heart of Birmingham PCT
Mark JeskyResearch Registrar
Background• Most management of diabetes (and microalbuminuria) takes
place in primary care
• Factors associated with development and progression of nephropathy well established– Good glycaemic control– Blood pressure management– ACEi/ ARB as antihypertensive agents of choice
• CKD frequently under-recognised
• Nephrology input later in course of disease
Background
• HoB PCT– Young, ethnically diverse population– has the highest take up rate of renal replacement
therapy within UK
– Enhanced, electronic recording of individuals• ≥40 years or identified as having a vascular disease
• Gain insight into practice within primary care setting
NICE CKD Guidelines: Diabetes
Audit Questions
• What is the extent of albuminuria within primary care diabetic population?
• Are NICE CKD guidelines being followed?– checking eGFR and ACR at least annually– if ACR elevated, are ACEi/ARBs being prescribed?
• Are any factors (age, gender, ethnicity) associated with not having ACR performed?
Diabetes and Measurement of Renal function
• June 2011 extract• 21,529 classified as diabetic– HoB population ≈ 300,000– 7.2%
• Of those 21,529, within last 12 months– 69.0% (14,854) had an eGFR recorded– 69.0% (14,857) had an ACR recorded
• 62.5% in National diabetes audit 2010• ~50% National diabetes audit 2008
– 51.2% (11,033) have both eGFR and ACR
Degree of Albuminurian= Normo-
albuminuraMicro-albuminuria
Macro-albuminuria
Male 7632 5204(68.2%)
1982(26.0%)
446(5.8%)
Female 7225 5493(76.0%)
1375(19.0%)
367(5.1%)
Combined 14857 10697(72.0%)
3357(22.6%)
803(5.4%)
National Diabetes Audit 73.5% 19.1% 7.4%
4140 (28%) diabetic individuals in HoB PCT have some degree of albuminuria
Adherence to NICE guidelines(Both ACR and eGFR reported)
eGFR ≥ 60 eGFR 30 -59 eGFR <30
No AlbuminuriaACR ≤ 2.5 (M), ACR ≤ 3.5 (F)
6335(57.4%)
1439(13.3%)
63(0.57%)
AlbuminuriaACR > 2.5 (M),ACR > 3.5 (F)
1963(17.8%)
1017(9.2%)
216(2.0%)
Adherence to NICE guidelines(Both ACR and eGFR reported)
eGFR ≥ 60 eGFR 30 -59 eGFR <30
No AlbuminuriaACR ≤ 2.5 (M), ACR ≤ 3.5 (F)
6335(57.4%)
1439(13.3%)
63(0.57%)
AlbuminuriaACR > 2.5 (M),ACR > 3.5 (F)
1963(17.8%)
1017(9.2%)
216(2.0%)
42.6% have either albuminuria or moderate CKDc.f. 45% in National Diabetes Audit
Adherence to NICE guidelinesACEi/ ARB usage
eGFR ≥ 60 eGFR 30 -59 eGFR <30
No AlbuminuriaACR ≤ 2.5 (M), ACR ≤ 3.5 (F)
6335(57.4%)
1439(13.3%)
63(0.57%)
AlbuminuriaACR > 2.5 (M),ACR > 3.5 (F)
1963(17.8%)
1017(9.2%)
216(2.0%)
Of these 2980,
68.2% (2032) on ACEi/ARB,31.8% (948) not
Checking ACR
• Demonstrated ACR not consistently checked• Can any factors associated with this be
identified?
Checking ACRACR measured ACR not measured
Gender (% female) 48.6 (100) 50.6 (100)
Age (years) 61.0 (100) 58.6 (100)
Systolic BP (mmHg) 132.6 (97.9) 132.4 (93.3)
Diastolic BP (mmHg) 76.0 (99.8) 76.6 (96.1)
HbA1c (%) 7.6 (96.9) 7.7 (93.0)
eGFR (% <60ml/min) 32.7 (76.3) 21.1 (69.0)
Bangladeshi (%) 72.3 27.7Black (%) 72.8 27.2Indian (%) 72.4 27.6Pakistani (%) 64.4 35.6White (%) 68.9 31.1Not Stated (%) 67.5 32.5
Checking ACRACR measured ACR not measured
Gender (% female) 48.6 (100) 50.6 (100)
Age (years) 61.0 (100) 58.6 (100)
Systolic BP (mmHg) 132.6 (97.9) 132.4 (93.3)
Diastolic BP (mmHg) 76.0 (99.8) 76.6 (96.1)
HbA1c (%) 7.6 (96.9) 7.7 (93.0)
eGFR (% <60ml/min) 32.7 (76.3) 21.1 (69.0)
Bangladeshi (%) 72.3 27.7Black (%) 72.8 27.2Indian (%) 72.4 27.6Pakistani (%) 64.4 35.6White (%) 68.9 31.1Not Stated (%) 67.5 32.5
Audit Questions
• What is the extent of albuminuria within primary care diabetic population?
• Are NICE CKD guidelines being followed?– checking eGFR and ACR at least annually– if ACR elevated, are ACEi/ARBs being prescribed?
• Do any factors (age, gender, ethnicity) predispose to not having tests done?
Summary• ACR assessed in under 70% diabetic population• Just over half had ACR and eGFR recorded in last 12 months
• ACEi/ ARB usage not as extensive as should be
• People with ACR not checked tend to be – Younger– Pakistani, White, ethnicity not stated– Less likely to have eGFR <60– Less likely to have other parameters checked
• Implications for risk stratification• More can be done to try to reduce rate of progression in this high risk
population
Acknowledgements
• Amanda Lambert• Dr Felix Burden• Dr Paul Cockwell
